Vital Signs Chapt. 29

Which information about a patient's pain is accurate? It is a subjective experience. A high score on the rating scale indicates little pain. The nurse is the expert on the patient's pain. A measurement of 0 to 10 mm Hg is expected. NOT SURE

It is a subjective experience.

Which statement from the nurse indicates appropriate clinical judgment in choosing a temperature assessment site? "Because the patient has a low white blood cell count, I will not take a rectal temperature." "The unconscious patient will benefit the most from temperature readings taken via the oral route." "The older adult patient has been sipping on cool water because of dehydration, but an accurate oral temperature reading is still possible." "Because the pediatric patient is slightly perspiring, temperature measurement by the temporal artery on the forehead will be avoided." NOT SURE

"Because the patient has a low white blood cell count, I will not take a rectal temperature"

Which instruction will the nurse give the parent who asks how much aspirin should be given to a 3-year-old with a viral infection? "Follow the dosing on the label." Let the parent know the standard dose. "Do not give the medication." "Use the dosage cup with the medication."

"Do not give the medication"

Which response indicates a nurse has a correct understanding about the components of a vital sign assessment? "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." "Respiration is the measurable amount of oxygen available to the tissues." "Blood pressure is the measurable pressure of blood within the systemic veins."

"Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart."

Which statement from the nurse indicates a correct interpretation of a higher temperature at 1830 when compared to the temperature at 1600? "It is normal for temperatures to fluctuate from one hour to the next." "I should start taking the temperature every 30 minutes." "This is a typical response based on circadian rhythms." "This should be reported immediately to the health care provider."

"This is a typical response based on circadian rhythms"

Which statements from the nurse indicate a correct understanding of assessment sites for temperature? Select all that apply. "Rectal temperature readings are avoided for infants." "I can get an accurate tympanic temperature reading on an unconscious patient." "A patient who uses an oxygen mask may have an inaccurate temperature measurement if taken by mouth." "I can get an accurate temperature reading by placing the thermometer to the right of the patient's axilla." "I can use temperature-sensitive strips on the forehead for the patient who is diaphoretic."

"rectal temperature readings are avoided for infants" "I can get an accurate tympanic temperature reading on an unconscious patient" "A patient who uses an oxygen mask may have an inaccurate temperature measurement is taken by mouth"

Which patient temperature measurements would cause the nurse to intervene? Select all that apply. Newborn: 96°F (35.5°C) 6-year-old: 98.6°F (37°C) 15-year-old: 100°F (37.8°C) Adult: 97.9°F (36.6°C) Older adult: 93°F (33.9°C) NOT SURE

15-year-old: 100°F (37.8°C)

Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? Select all that apply. 158 pulse rate 8 respirations 99.5°F (37.5°C) temperature 98% oxygen saturation 50/30 blood pressure NOT SURE

158 pulse rate 8 respirations 50/30 blood pressure

Infants under the age of ___ months have immature regulatory thermoregulation systems.Record answer as a whole number.

3

Which vital sign measurements are unexpected? Select all that apply. 99.5°F (37.5°C) temperature for a newborn 60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old 110/68 blood pressure for an older adult NOT SURE

60 pulse rate for a 1-year-old 35 respirations for a 6-year-old SpO2 90% for a 15-year-old

What is the expected pulse range for an adult patient? Record your answer as whole numbers separated by a hyphen.

60-100

Which temperature range is expected for an adult patient? 99.4° to 99.7°F (37.4° to 37.6°C) 98° to 98.6°F (36.6° to 37°C) 93.2° to 96.8°F (34° to 36°C) 95.9° to 99.5°F (35.5° to 37.5°C) NOT SURE

95.9° to 99.5°F (35.5° to 37.5°C)

Which interventions would the nurse select for a patient with hypothermia who was rescued from drowning in a freezing river? Select all that apply. Administer prescribed warmed intravenous fluids. Apply several layers of warmed blankets. Keep the patient's wet clothing on to avoid heat loss. Wrap warm, dry towels around the patient's head. Apply a cooling blanket to keep the body accustomed to the cold.

Administered prescribed warmed intravenous fluids Apply several layers of warmed blankets Wrap warm, dry towels around the patients head

Which pulse site would the nurse use that is the most definitive site to determine a patient's cardiac health? Apical Radial Peripheral Carotid

Apical

Which actions are strictly a nurse's responsibility? Assess patients to determine if medically stable Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values. Measure vital signs for stable patients.

Assess patients to determine if medically stable Interpret vital sign measurements. Report significant vital sign findings to the health care provider. Reassess any unexpected vital sign values.

Which action would the nurse take before notifying the health care provider about a patient's vital signs?

Compare the findings to the patients baseline

Match the mechanism of heat loss to its intervention. Cooling a patient with a fan Positioning a patient close to a cold window Placing a cool rag on the patient's forehead Checking the patient with a fever for diaphoresis

Cooling a patient with a fan: convection Positioning a patient close to a cold window: conduction Placing a cool rag on the patients forehead: radiation Checking the patient with a fever for diaphoresis: evaporation

Which entries would the nurse include when documenting vital signs? Select all that apply. Date of assessment Time of assessment Names of visitors in the room Numeric results of the assessment Expected values for vital signs

Date of assessment Time of assessment Numeric results of the assessment

Which cues would the nurse likely observe in a patient who has hyperthermia? Select all that apply. Dizziness Hot skin Cool, white skin Rapid heart rate Increased urinary output

Dizziness Hot skin Rapid heart rate

Which actions are required for proper documentation of vital signs? Recording duplicate entries Documenting in a standardized format Recording on a specified form Recording just expected values

Documenting in a standardized format Recording on a specified form

Which cues would the nurse likely observe in a patient who has a temperature of 92°F (33.3°C)? Select all that apply. Drowsiness Muscle cramps Excessive thirst Pale, cool skin Decreased urinary output

Drowsiness Pale, cool skin Decreased urinary output

Which actions are responsibilities of the nurse when assigning vital signs to the unlicensed assistive personnel (UAP)? Select all that apply. Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Determine that the UAP knows to report unexpected values to the health care provider. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment.

Ensure that the UAP uses the proper technique for measuring vital signs. Validate that the UAP knows what values need to be reported immediately for each patient. Ensure that the UAP is competent to perform vital sign assessments. Validate that the UAP uses appropriate equipment

How frequently would the nurse take vital sign measurements for a stable hospitalized patient?

Every 4 to 8 hours

How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94? Every 5 minutes Every 30 minutes Every 4 hours Every 8 hours NOT SURE

Every 5 Minutes

Match each condition with its proper definition. Exposure to extreme cold, resulting in low body temperature Ice crystals form inside cells, causing tissue damage Rise in body temperature above expected, caused by trauma or illness High body temperature, caused by prolonged exposure to extreme heat

Exposure to extreme cold, resulting in low body temperature: Hypothermia Ice crystals form inside cells, causing tissue damage: Frostbite Rise in body temperature above expected, caused by trauma or illness: Fever High body temperature, caused by prolonged exposure to extreme heat: Hyperthermia

Which factors can affect a patient's heartbeat? Select all that apply. Fever Hunger Exercise Medications Hypovolemia

Fever Exercise Medications Hypervolemia

Place the steps in order when caring for a patient who is febrile. Reassess temperature to evaluate care for Fever. Analyze cues to determine hypothesis of Fever. Develop expected outcomes. Administer antipyretic. Select solutions for Fever. Gather cues from the temperature assessment. NOT SURE

Gather cues from the temperature assessment Analyze cues to determine hypothesis of fever Devevop expected outcomes Select solutions for fever Administer antipyretic Reassess temperature to evaluate care for fever

Which assessment question would the nurse ask a patient prior to measuring temperature? "Do you have a family history of fevers?" "Have you exercised in the last 30 minutes?" "How would you describe your body temperature?" "At which site would you like me to take your temperature?"

Have you exercised in the last 30 minutes

Match the intervention to its pathophysiologic cause. Heat-loss processes outpace heat-generating processes Heat-generating processes overcome heat-loss processes Heat-loss processes equal heat-generating processes Hypothalamus set-point is elevated

Heat-loss processes outpace heat-generating processes: Institute rewarming measures Heat-generating processes overcome heat-loss processes: Institute cooling measures Heat-loss processes equal heat-generating processes: Use measures to maintain expected temperature Hypothalamus set-point is elevated: Administer antipyretics

Which items would the nurse offer to a patient with a low body temperature? Select all that apply. Hot soup Head coverings Regular hot tea or coffee Warmed blankets Warmed intravenous fluids NOT SURE

Hot Soup Head coverings Warmed blanket Warmed intravenous fluids

Which part of the brain maintains a consistent internal body temperature despite environmental extremes? Thalamus Brainstem Cerebellum Hypothalamus

Hypothalamus

Which nonpharmacologic interventions lower a patient's fever? Select all that apply. Ice packs Acetaminophen Cooling pads Cool sponge baths Warmed blankets

Ice packs Cooling pads Cool sponge baths

Which situations require vital sign assessment?

In ongoing care During an inpatient stay Before and after surgery As part of a physical assessment

Which mechanism of action would lower a patient's temperature when taking antipyretics? Increase prostaglandin production Lower the hypothalamus set-point Reduce heat-loss processes Transfer of heat as waves or particles of energy

Lower the hypothalamus set-point

Which actions would the nurse take for a patient who has a fever? Select all that apply. Lower the room temperature. Decrease stress level. Encourage ambulation. Monitor red blood cell count. Review culture and sensitivity reports.

Lower the room temperature Decrease stress level Review culture and sensitivity reports

Which internal process provides the primary source of heat production? Exercise Hormones Metabolism Convection NOT SURE

Metabolism

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Teenager who is afebrile Older adult patient with a fever Middle-aged adult with heatstroke Young adult with a fever

Middle age adult with heatstroke Older adult patient with a fever Young adult with a fever Teenager who is afebrile

Match the characteristic with the correct temperature assessment site. Most common site for measuring temperature Measures core or deep tissue temperature Tolerated by infants and young children Very accurate reading but not preferred by patient

Most common site for measuring temperature: oral Measure Core or deep tissue temperature: tympanic Tolerated by infants and young children: temporal Very accurate reading but not preferred by patient: rectal

Which patient would the nurse monitor closely for alterations in temperature control? One who requires assistance with activities of daily living One who just received a series of x-rays for a broken leg during a sports game One who is undergoing a routine wellness examination prior to an international flight One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)

One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)

Which patient would the nurse assess first? One with heatstroke One who has controlled diabetes One with anorexia One who has an infection NOT SURE

One with heatstroke

Which factors influence the interpretation of a patient's vital signs? Select all that apply. Patient status Length of time the nurse is on duty Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition NOT SURE

Patient status Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition

When the nurse is reviewing medications, for which patients would the nurse need to notify the health care provider? Select all that apply. Patient with liver disease who is receiving acetaminophen Patient with a fever who is receiving ibuprofen Patient with an acetaminophen prescription for 3 grams/day Patient who is taking an anticoagulant and aspirin for fever Patient who has a bleeding disorder taking ibuprofen NOT SURE

Patient with liver disease who is receiving acetaminophen Patient who is taking an anticoagulant and aspirin for fever Patient who has a bleeding disorder taking ibprofen

Which finding takes precedence when interpreting a patient's vital sign values?

Patients baseline result

Which outcome would the nurse develop for a patient who is afebrile? Patient's temperature will return to expected range within 1 hour of treatment. Patient's temperature will be within the expected range until discharge. Patient's temperature will increase by 1° until within the expected range. Patient's temperature will decrease by 1° until within the expected range.

Patients temperature will be within the expected range until discharge

Which cues would prompt the nurse to select Fever as a hypothesis? Select all that apply. 93°F (33.9°C) Presence of infection Chills Anorexia Dehydration Cool skin

Presence of infection Chills Anorexia Dehydration

Which action would the nurse take when measuring the tympanic temperature of a 5-year-old? Pull the ear down and back. Pull the pinna up and back. Angle the probe toward the umbilicus. Angle the probe toward the forehead.

Pull the pinna up and back

Which measurements are included as cardinal vital signs?

Pulse, respirations, blood pressure

Which mechanisms primarily enhance heat loss from the body? Select all that apply. Radiation Digestion Conduction Convection Evaporation

Radiation Conduction Convection Evaporation

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)? Advise the UAP to wait 1 hour and repeat vital signs. Compare the findings to the expected values. Reassess the patient. Tell the UAP to give fluids to the patient. NOT SURE

Reassess the patient.

Match the intervention with its mechanism of action. Reduce metabolic demands and oxygen use Identify the most effective antibiotics Help meet the increased metabolic demands produced by fever Replace losses from increased respirations and diaphoresis

Reduce metabolic demands and oxygen use: sleep and rest Identify the most effective antibiotics: laboratory test Help meet the increased metabolic demands produced by fever: oxygen and nutrients Replace losses from increased respirations and diaphoresis: oral and IV fluids

Which tasks would the nurse delegate to the unlicensed assistive personnel (UAP)?

Report vital signs for a stable patient Measure vital signs for a stable patient

Which finding is unexpected for a 15-year-old patient? Pain level 0 Pulse rate 88 Respirations 30 O2 sat 97% NOT SURE

Respirations 30

Which vital sign finding indicates the adult patient is improving? Blood pressure changes from 120/78 to 80/60. Pulse rate increases from 85 to 110. Oxygen saturation changes from 90% to 85%. Respiratory rate decreases from 36 to 20.

Respiratory rate decreases from 36 to 20.

Which cues related to thermoregulation can be found in the medical record? Select all that apply. Results of white blood cell count Presence of growth on a culture Patient interview Temperature readings on graphics Levels of hormones NOT SURE

Results of white blood cell count Presence of growth on a culture Temperature readings on graphics Levels of hormones

Which action would the nurse take after developing outcomes for a patient with a fever? Determine goals with the patient. Implement care. Select solutions. Check the chart for laboratory results. NOT SURE

Select solutions

Which site is the natural pacemaker of the heart? Sinoatrial node Atrioventricular node Purkinje fibers Internodal pathway NOT SURE

Sinoatrial node

Which factors affect body temperature? Select all that apply. Stress Height Smoking Hormones Environment Circadian rhythms

Stress Smoking Hormones Environment Circadian rythms

Which action by the nurse supports the hypothesis of Hypothermia when the patient presents with decreased respirations, cool skin, and low body temperature? Ask the patient about feeling feverish. Request laboratory work to check the patient's iron levels. Check the patient's urinary output, which is increased. Take the patient's blood pressure, which shows hypotension.

Take the patients blood pressure, which shows hypotension

Which action would the nurse take for a stable patient who is scheduled for a transfer to the rehabilitation unit later in the afternoon? Take vital signs before the transfer. Require every 2-hour monitoring until the transfer. Monitor the pulse rate once a day after the transfer. Delay vital signs monitoring since the patient is being transferred.

Take vital signs before the transfer.

Which cues alert the nurse that a patient with hyperthermia is declining? Select all that apply. Temperature increases. Temperature decreases. White blood cells decrease. Heart rate increases. Dizziness increases.

Temperature increases Heart rate increases Dizziness increases

Which cues alert the nurse a patient with hypothermia is improving? Select all that apply. Temperature decreases. Temperature increases. Urinary output increases. Blood pressure decreases. Culture growth decreases.

Temperature increases Urinary output increases

Which explanation would the nurse make when discussing a patient's cardiac output? The number of heartbeats in 1 minute The amount of blood the heart pumps per minute The amount of time it takes for one cardiac cycle The number of pulse sites that are palpable NOT SURE

The amount of blood the heart pumps per minute

Which instruction would the nurse share with a male patient who calls the clinic and tells the nurse that over a 24-hour period he has taken two extra strength acetaminophen tablets (1000 mg) every 4 hours for a fever? Acetaminophen is a drug that will reduce your fever. Continue to take the drug. This is too much acetaminophen. You have probably damaged your liver.

This is too much acetaminophen

Which areas of the human body are most vulnerable to frostbite? Select all that apply. Toes Wrists Earlobes Abdomen Tip of nose NOT SURE

Toes Earlobes Tip of nose

Which action would the nurse take immediately after assessing a patient's temperature to determine whether the patient has heat exhaustion or heatstroke? Touch the patient's skin. Retake the patient's temperature. Start the prescribed antibiotic. Obtain a culture and sensitivity test.

Touch the patients skin

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports an adult patient has a 99.5°F (37.5°C) temperature? Recognize this is an expected finding. Immediately notify the health care provider. Tell the UAP to start taking the temperature every 1 hour. Inform the family that the patient may be transferred.

recognize this is an expected finding